Well here we are again, albeit a little sooner than anticipated, with a new project! Our previous review topic (effectiveness of different social work models) has been put to one side pending the publication of more primary research and we’re already sinking our teeth into something new.
The “something new” is organisational interventions aiming to reduce the length of hospital stay (LoS) for older adults undergoing elective surgery. The focus on “elective”, or planned, surgery arose due to interest in supporting hospitals to undertake a proactive approach to managing known factors which may increase the duration of a patient’s stay in hospital.
Our starting point was to identify and understand the factors which may increase LoS and available hospital-based interventions used to manage these. We spoke to a local consultant geriatrician, who helped us to think about the typical journey an older person through the hospital system. We also discussed how the responsibility for ensuring that this potentially vulnerable patient group has an appropriate length of stay does not just lie with the hospital itself. These early conversations helped us focus our search for a relevant research question.
In At the Deep End…
The next step was to look in the published literature to help us understand the different factors which may influence an older person’s LoS. We had a splash course in getting up to speed with some of the existing organisational interventions used to reduce length of hospital stay, such as Enhanced Recovery After Surgery programmes (ERP/ERAS) and Comprehensive Geriatric Assessments (CGA). As none of the team hold medical degrees, getting to grips with the names of some medical procedures provided an interesting challenge!
Our preliminary scoping searches revealed that this is an area which has generated a lot of interest, including several existing systematic reviews (e.g. Bagnall et al (2014), Conroy et al (2011)). This is perhaps unsurprising given the increased demand experienced by many health services by an older population. If the literature base for social work was too sparse to justify conducting a systematic review, here we appeared to have the opposite problem; identifying a clinically useful question with an associated body of research, which has not already been reviewed. We did not want to conjure up a research question based upon an identified gap in the literature, which was academically interesting but of no use to clinicians/service managers on the ground. Likewise, we needed to make sure that some of the clinical issues we had identified had not already been subject to a systematic review.
A Guiding Light: The Role of Expert Advice
Discussions continued with our clinical colleagues – we enlisted the help of a physiotherapist and occupational therapist in addition to our friendly consultant geriatrician. This provided us with some knowledge of the organisational systems in NHS hospitals which aim to ensure patients receive the care appropriate to their needs with minimal potential harms which in turn aided us in focusing our research question. We will be continuing these conversations and expanding them to include patients, other clinicians and service managers as the review progresses to ensure that it remains relevant to those it is intended to benefit.
Circling the Question Generation Cycle
With lots of background knowledge and reading (e.g. Miani et al, 2014; Paton et al, 2014) under our belts we began the “Idea for a question – explore existing research – back to question” cycle. Each iteration through the cycle resulted in the team becoming more immersed in the research. This was a strange period of uncertainty and doubt. Often it felt as though we were taking two steps forward, followed by one-step back, as our preliminary scoping resulted in us returning to older ideas that had been proposed earlier in the process. Some of our early question ideas were as follows:
- A systematic review of qualitative research to identify and explore the influencing factors necessary for successful implementation of an ERAS/ERP intervention.
- A conceptual mapping review to better define/produce a typology of interventions aiming to reduce length of stay.
- A systematic review identifying key components of an ERP intervention for different patient populations (people with dementia etc.).
Spreadsheets and mind-mapping were useful tools to help anchor our thoughts and keep track of progress. Whilst initially frustrating and a little overwhelming, over time our familiarity with the existing literature grew and we were able to refine our ideas.
And Our Question Is….
Whilst all the above questions may represent important topics to address through systematic review, we kept returning to the broad concept of wanting to know whether existing organisational interventions were effective for older adults within a hospital setting. We decided that our focus should continue to be broader than elective surgery and also encompass other elective treatments, such as chemotherapy.
Hence, it was decided that our research questions should be:
- What is the effectiveness of hospital-based interventions to reduce length of inpatient stay in hospitals for older adults following planned admission?
- What is the cost-effectiveness of hospital-based interventions to reduce length of inpatient stay in hospitals for older adults following planned admission.
Just Keep Swimming
Of course that wasn’t the end of the story, discussions continued to further refine and define the components of the question – some of the things we’ve been grappling with are:
- Who is an “older” patient? What does being “old” mean, exactly? Is it your number of years on this planet, or is it the change in your health and the support you need as you age? This question has been approached in many different ways….
- What is an elective treatment? Do we include people who were admitted to an Intensive Care Unit after undergoing an elective treatment? It’s hardly a treatment pathway someone decides they’d like, but there is potential to develop a planned care package in advance.
- What is an organisational intervention? What is the definition of an organisational intervention? We want to know what it is that is being done, how it is being implemented and who it carrying it out. Some of the studies exploring the effectiveness of certain types of intervention (e.g. CGA) don’t tell us much about what the intervention consists of or how it is carried out.
- How can we usefully define “length of stay”? Is it just the number of days in hospital after the first admission or should we also be interested in readmission data? How is that defined clinically and in research studies?
- How can we judge whether interventions intended to reduce length of stay? Should LOS be the primary intended outcome in our included studies? Should we include only those that stated this as their aim, or also those that said they aimed to ‘improve recovery’ or ‘accelerate rehabilitation’? Or should we include evaluations of all eligible hospital-based interventions where LOS is an outcome measure?
We have made decisions about most of these uncertainties, based on stakeholder input, pilot screening and discussion among the team, but still have some more thinking to do. Stay tuned whilst we dig into the nitty gritty of defining our inclusion and exclusion criteria and (hopefully!) turn this grain of sand into a pretty pearl.